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  • • Etiologies include:

    • -Branchial cleft remnants

      -Thyroglossal duct cyst

      -Lymphadenopathy

      -Vascular malformations and cystic hygroma

      -Dermoid inclusion cysts

      -Cervical thymic cysts

    • Branchial cleft remnants

    • -Present most commonly as cysts later in childhood

      -Sinuses, fistulae, and cartilage remnants present at birth

      -Second branchial cleft remnants most common

    • Thyroglossal duct cyst presents later in childhood

    • Benign lymphadenopathy most common neck mass of childhood

    • -Usually secondary to upper respiratory tract infections

      -Occasionally accompanied by suppurative lymphangitis

    • 65% of lymphangioma and cystic hygroma are present at birth and 80% are present by age 1

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Symptoms and Signs

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  • Branchial cleft cysts

    • -Present later in childhood when secretions build up, occasionally with erythema and tenderness due to infection

      -Present from angle of mandible (first cleft) down to lower third of sternocleidomastoid (second cleft) with fistulas being present to external auditory meatus (first), tonsillar fossa (second), pyriform sinus (third and fourth)

      -Masses or cysts can present anywhere between fistula openings and internal cleft sites

    Thyroglossal duct cyst

    • -Presents as midline cystic neck mass usually overlying hyoid

      -Often moves during swallowing or draining sinus in early childhood

      -Occasionally presents as painful draining mass if infected

    Suppurative lymphangitis: Presents as painful, erythematous, draining mass following an upper respiratory tract infection

    Hemangiomas: Become apparent after first few weeks of life usually as blue, spongy, rubbery, and sometimes extensive in cutaneous regions or airway

    Lymphangioma and cystic hygroma: Typically present as asymptomatic mass anywhere in body but have a high tendency to become infected

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Imaging Findings

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  • • Barium injection or CT often required to demonstrate fistula tract for branchial cleft remnants

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  • • Malignant degeneration (rare) or infection in branchial cleft remnants

    • Malignancy in lymph nodes

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Rule Out

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  • • Malignant lymph nodes and infection with atypical bacteria such as mycobacterium

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  • • History and physical exam

    • Barium injection of fistula tract for branchial cleft fistula

    • CT for suspected branchial cleft remnants

    • US with duplex for some masses difficult to diagnose

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Surgery

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  • • Incision and drainage of branchial cleft cyst if infected

    • Dissection and excision of branchial cleft cyst or fistula once infection resolved

    • Thyroglossal duct cyst excision including midpoint of hyoid and tract up to base of foramen cecum

    • Incision and drainage of suppurative lymphangitis if initially unresponsive to antibiotics

    • Excisional biopsy for enlarged lymph node present > 8 wks, larger than 2 cm, firm, immobile

    • Excision or sclerotherapy of lymphangioma or cystic hygroma

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Contraindications

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  • • Definitive excision contraindicated in presence of active infection

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Medications

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  • • Intralesional corticosteroid or systemic corticosteroid for hemangioma that can compress airway or obstruct eyes

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Complications

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  • • Injury to other structures of neck for branchial cleft remnants such as facial nerve, hypoglossal nerve, ...

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